AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Hippocrates described an array of facial injuries as long ago as 400 BCE. In 1823, von Graeffe described the use of an elastic tube placed in the nares to maintain an open airway. During the early 20th century, Sir Harold Gilles, father of plastic surgery, taught army personnel about breathing problems in patients with facial injuries. He recommended positioning them supine to maintain an airway. Frenchman René Le Fort studied cadavers in 1901 and described 3 basic types of facial fractures. Endotracheal anesthesia and radiography, developed during the First World War, led to a better understanding and treatment of facial fractures. During the Second World War, a multidisciplinary approach to treatment of facial fractures continued to improve outcomes of severely injured soldiers. Advent of CT-guided reconstruction, along with new surgical techniques, has improved the final appearance of patients with bony injuries immensely.

Pathophysiology

Maxillofacial fractures are the result of blunt or penetrating trauma. Most are blunt injuries caused by vehicular crashes, altercations, sporting-related trauma, occupational injuries, and falls. Penetrating injuries are mainly the result of gunshot wounds, stabbings, and explosions.

Determinants of type of injury (ie, soft tissue alone vs bony) are shape and velocity of the striking object.

The amount of force needed to fracture different bones of the face has been studied, and these bones have been divided into those that require high impact to fracture (greater than 50 times the force of gravity [g]) and those that require only low impact to fracture (less than 50 g).

• High impact
• • Supraorbital rim - 200 g
  • Symphysis of the mandible - 100 g
  • Frontal-glabella - 100 g
  • Angle of mandible - 70 g
• Low impact
• • Zygoma - 50 g
  • Nasal bone - 30 g

Mandibular fractures usually occur in 2 or more locations because of the bone's U shape and articulations at the temporomandibular joints. Fractures also may occur at a site apart from the site of direct trauma. A large percentage of mandibular fractures are open, as they often fracture between teeth and communicate with the oral cavity.

Different mechanisms are associated with varying locations. Fractures from automobile crashes most frequently occur at the condyle and symphysis, those from motorcycle accidents at the symphysis and alveolus, and those from altercations mostly at the condyles, angles, and body.

For more information, see Medscape's Trauma Resource Center.

Frequency

United States

The mandible is the third most fractured bone of the face. Of these fractures, approximately 20-35% are at the condyle and ramus, 20-30% at the angle, 15-30% at the body, 8-20% at the symphysis, and 1-5% at the alveolar ridge.

One study placed the incidence of severe maxillofacial injury (fractures, lacerations) at 0.04-0.09% for motor vehicle crashes. Incidence of fractures due to motor vehicle injuries is higher in rural areas; altercation-related injuries are more frequent in inner cities.

Mortality/Morbidity

• Incidence of other major injuries is as high as 50% in high-impact mandibular fractures, whereas it is 21% in low-impact fractures. Mortality rate in high-impact fractures is as high as 12%, yet death rarely results directly from maxillofacial injury.
• Patients who are involved in motor vehicle crashes are more likely to have additional injuries than patients with violence-related injuries.
• Incidence of associated cervical spine injuries ranges from 0.2-6%.

Sex

Adult male-to-female ratio is 3:1. Suspect domestic violence or sexual assault in women as this may coexist in 30% of cases.

Age

Male predominance is reduced to 3:2 in children. In nonmotor vehicle injury, the possibility of child abuse should be a concern.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Since maxillofacial fractures are the result of trauma, primary survey and attention to airway, breathing, and circulation takes priority.
• Focus primary evaluation on patency of airway, control of cervical spine, breathing and circulatory impairment, and loss of consciousness if patient is experiencing neurologic impairment.
• Once life threats are addressed, obtain a thorough history.
• • Allergies
  • Medications
  • Medical history
  • Last meal
  • Events leading to injury
• Next, ask specific questions regarding the facial injury.
• • Does patient have epistaxis or clear fluid running from nares or ears?
  • Did patient lose consciousness? If so, for how long?
  • Has patient had any visual problems, such as double or blurred vision?
  • Has patient had any hearing problems, such as decreased hearing or tinnitus?
  • Does patient have any malocclusion, and is patient able to bite down without pain?
  • Does moving the jaw cause pain or spasm?
  • When the jaw moves, is a grinding sound produced?
  • Does the patient have areas of numbness or tingling on the face?
  • In women, ask if the injury was from a partner or if they feel threatened by anyone.
  • In children, ask questions to determine if child abuse is an issue.

Physical

• Complete exam of the face is necessary, since multiple injuries can occur easily. Portions of the exam specific to the mandible are marked with an asterisk (*).
• • Inspect face for asymmetry, performed while looking down from head of bed.
  • Inspect open wounds for foreign bodies and palpate for bony injury.
  • Palpate bony structures of supraorbital ridge and frontal bone for step-off fracture.
  • Thoroughly examine eyes for injury, abnormal ocular movements, and visual acuity.
  • Inspect nares for telecanthus and widening of nasal bridge, then palpate for tenderness and crepitus.
  • Inspect nasal septum for septal hematoma and clear rhinorrhea, which may suggest cerebrospinal fluid (CSF) leak.
  • Palpate zygoma along its arch as well as along its articulations with the frontal bone, temporal bone, and maxillae.
  • Check facial stability by grasping teeth and hard palate and gently pushing back and forth then up and down, feeling for movement or instability of midface.
  • *Test teeth for stability and inspect for bleeding at gumline, a sign of fracture through the alveolar bone.
  • *Check teeth for malocclusion and step-off.
  • *Palpate mandible for tenderness, swelling, and step-off along its symphysis, body, angle, and coronoid process anterior to the ear canal.
  • *Check for localized edema or ecchymosis in the floor of the mouth.
  • Evaluate distributions of the supraorbital, infraorbital, *inferior alveolar, and *mental nerves for anesthesia.
  • *If teeth are missing, account for them to ensure they have not been aspirated.
  • *Inspect area just anterior to the meatus of the ear for ecchymosis and palpate for tenderness. This is the condyle of the mandible and site of an often-missed fracture. Plain radiographs are not good at visualizing the condyle, thus maintain a high level of suspicion if physical exam is suggestive.
  • *Mandibular fracture is suggested by inability to open mouth, trismus, malocclusion of teeth, or palpable step-offs of bone along symphysis, angles, or body. Gingival bleeding at the base of a tooth suggests fracture, especially if teeth are malaligned. Edema or ecchymosis may be present in the floor of the mouth. Neurologic findings may include hypesthesia in distribution of inferior alveolar or mental nerves.

Causes

• Motor vehicle accidents, as occupant or as pedestrian stuck by the vehicle
• Violence, by being struck with fists, feet, or objects including bullets in penetrating injuries
• In falls, either from a height or in cases of syncope 

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Airway obstruction
Aspiration of avulsed teeth
Other major traumatic injuries
Dentate, avulsed
Dentate, displaced
Dentate, fractures

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Direct laboratory studies toward workup of a trauma patient. If this is an isolated injury, laboratory studies may not be required.
• If fracture is an isolated injury, obtain preoperative labs if surgery is planned.

Imaging Studies

• Radiographs
• • Best plain film to assess the mandible is a panorama view (ie, Panorex), which shows the mandible in its entirety in a single view. Panoramic view is not always available, as it requires a special radiographic machine. If panorama view is not available or patient is unable to sit for film, obtain routine mandible films.
  • Routine views include bilateral lateral oblique projections to look at the angle, body, and to a lesser extent, symphysis, and Townes view to look at the condyles.
  • Submental view can be helpful in evaluating the symphysis.
  • Obtain chest films of patients with unaccounted missing teeth to rule out aspiration.
  • Cervical spine radiographs may be indicated with severe facial injuries or in patients with a consistent mechanism and neck pain.
• Computed tomography
• • In selected patients with nondiagnostic radiographs in whom mandibular fracture is suspected strongly, CT scan may be necessary to diagnose condylar fracture.
  • CT scans often are used to better evaluate fracture prior to surgical repair.
  • Consider CT scan of the brain to rule out intracranial injury.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• Airway, breathing, and circulation are the first priority. Hold airway open by jaw thrust or airway adjuncts, including endotracheal intubation.
• Treat hypoventilation with intubation and bag ventilation. Nasotracheal intubation is considered a relative contraindication with severe maxillofacial trauma because of concern for intracranial placement of endotracheal tubes.
• Suction usually is needed to keep airway free of blood and debris.
• Place patient on a backboard with a collar if cervical spine injury is a possibility.
• Control actively bleeding wounds by applying direct pressure with a bandage.

Emergency Department Care

• Airway, breathing, and circulation
• • Frequently assess airway. Isolated mandible fracture from a blunt mechanism usually does not require intubation, but frequent suctioning is mandatory.
  • Early intubation before swelling occurs makes airway control much easier, rather than waiting until a problem arises from obstruction. This is usually a clinical decision based on projected course.
  • Before using paralytics in an intubation, carefully evaluate the ability to manage the airway with a bag and mask or laryngeal airway. If unable to manage the airway, do not paralyze the patient. Fiber optic guides or bronchoscopic-guided intubation may be an option. If in doubt, prepare for a cricothyrotomy before attempting the airway with either sedation or paralytics.
  • Do not focus on obvious deformity, thereby forgetting to perform a complete primary survey. Rapidly diagnose other life threats and undertake appropriate resuscitation.
• Secondary survey
• • Diagnosis of mandibular fracture is part of the secondary survey of ED care, though it should be kept in mind when evaluating the airway in the primary survey.
  • A Barton bandage can be placed if the patient has no airway compromise by wrapping a gauze roll over the crown of head and around the jaw to provide support. Wrap a second gauze roll around forehead and back of head to hold first bandage in place.
  • Open fractures require antibiotics. Penicillin or one of the cephalosporins are current DOC. Penicillin-allergic patients can be given clindamycin.
  • The following procedure takes a fair amount of time and usually is performed by an ear, nose, and throat (ENT) or dental consultant.
  • • Erich arch bar can be used to hold fractures that are stable by placing arch bar around the base of the teeth and bending ends around the posterior molar.
    • Next, wire each tooth to the bar by wrapping a 26-gauge steel wire around base of tooth and then around arch wire and twisting it tight.
    • If maxillary teeth are to be used as a splint, they are wired in the same manner. Then, use elastic bands to tie the 2 arch wires together.
    • Remember, patient's mouth is now banded shut. Do not perform this procedure if the patient has a risk of vomiting or has problems with the airway.

Consultations

• Provide care for the multiple-injured patient in conjunction with a surgeon who has experience in trauma care.
• Definitive treatment of mandibular fractures is performed by an oral-maxillofacial surgeon or an ENT specialist.
• The incidence of posttraumatic stress disorder is high in patients with facial injuries, and consultation with a psychiatrist should be considered.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

When airway control is needed, rapid sequence induction often is the preferred method. Rapid sequence induction utilizes medications to induce unconsciousness and muscle paralysis to facilitate intubation. Cricothyroidotomy kit should be at the bedside in case problems arise.

Medication for pain control is appropriate, including NSAIDs, narcotics, and local anesthetics.

Patients with open fractures, which are the majority, should be given IV antibiotics. Current choices are penicillin or a cephalosporin. In penicillin-allergic patients, clindamycin is a good alternative. If the patient has an open wound, administer tetanus toxoid if the patient is not current.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

These agents are used most commonly for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Drug Category: Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Drug Category: Antibiotics

Prophylaxis is given to patients with open fractures. Therapy must cover all likely pathogens in the context of the clinical setting.

Drug Category: Tetanus toxoid

This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Drug Category: Immunoglobulins

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Fractures of the mandible can be stable (favorable) or unstable (unfavorable) depending on how the fracture line courses in the bone. Muscles attached to the mandible continue to exert their forces. Elevators of the mandible are the masseter, temporalis, and medial pterygoid, while depressors and retractors are the mylohyoid, geniohyoid, and anterior belly of the digastric. Lateral pterygoid is the protrusor of the mandible.
• Direction of fracture determines whether it is stable or unstable. Fractures running from posterior downward to anterior (favorable) generally are stable, because muscles pull the fragments together and can be treated with soft diet and arch wires if fragments are not aligned.
• Fractures of the body of the mandible running from anterior to posterior in a downward direction (unfavorable) usually are displaced and can be stabilized with wire bar fixation of upper and lower teeth. Unstable fractures may require open reduction and internal fixation if they are not reduced by wire fixation or if they are markedly unstable.
• An edentulous mandible usually is unfavorable, because the patient has no teeth to stabilize the fracture. A stable nondisplaced fracture in an edentulous patient may be splinted with his or her denture and the patient restricted to a diet of soft food. An unstable fracture usually requires internal fixation to maintain reduction.
• All open fractures and unstable fractures require admission. Depending on institution, some patients with stable fractures that require arch band fixation are treated and released from ED, while others are treated on an inpatient basis.

Further Outpatient Care

• Place patient on a diet of soft or pureed food.
• Instruct patient to return if any signs of infection are noted.
• If arch wires are in place, instruct patient on release of interwire bands and give proper tools. Inability to release bands can be fatal if the patient vomits or has an airway problem.

In/Out Patient Meds

• Medications such as NSAIDs, acetaminophen, and a short course of narcotics can be used for pain control.
• Liquid preparations of medications are preferable.

Transfer

• If appropriate specialists are not available in the receiving institution, arrange transfer to a higher-level hospital.

Deterrence/Prevention

• Use of seat belts and airbags can reduce incidence of facial injuries in motor vehicle crashes.
• Use of helmet with facial guards can reduce injury in motorcycle accidents and accidents in such sports as skiing, snowboarding, hockey, and football.

Complications

• Loss of airway
• Aspiration of avulsed teeth
• Infection
• Nonunion
• Malnutrition and weight loss if teeth are banded together
• Injury to inferior alveolar or, more distally, mental nerve
• Posttraumatic stress disorder

Prognosis

• Prognosis is generally favorable with proper treatment.

Patient Education

• Instruct patient on how to release Erich arch wire if he or she has problems with airway.
• Place patient on a diet of soft or pureed food.
• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center and Teeth and Mouth Center. Also, see eMedicine's patient education articles Broken Jaw.
• Patients should be informed of the high risk of posttraumatic stress disorder and be referred to a psychiatrist should symptoms occur.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to diagnose associated intracranial or cervical spine injuries because focus was on obvious injury
• Failure to account for missing teeth, which may have been aspirated

Special Concerns

• Always consider potential for loss of airway and intrathoracic, intraabdominal, and intracranial injuries.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Glynn SM, Asarnow JR, Asarnow R, et al. The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital. J Oral Maxillofac Surg. Jul 2003;61(7):785-92. [Medline].
• Hendler B. Maxillofacial trauma. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1998:1093-1103.
• McGill J, Ling L, Taylor S. Facial trauma. In: Diagnostic Radiology in Emergency Medicine. Mosby-Year Book; 1992:51-76.
• Smith R. Maxillofacial injuries. In: Harwood-Nuss A, ed. The Clinical Practice of Emergency Medicine. Lippincott, Williams & Wilkins Publishers; 1991:337-43.
• Snell R, Smith M. The face, scalp, and mouth. In: Clinical Anatomy for Emergency Medicine. Mosby-Year Book; 1993:206-41.
• Spoor T, Ramocki J, Kwito J. Ocular trauma. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. 2^nd ed. Lippincott, Williams & Wilkins; 1996:225-41.
• Sullivan W. Trauma to the face. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. 2^nd ed. Lippincott, Williams & Wilkins; 1996:242-69.
• McKay MP. Facial trauma. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 6^th ed. Philadelphia, PA: Mosby Elsevier; 2006:382-98/chap 39.
• Hasan N, Colucciello SA. Maxillofacial trauma. In: Tintinalli JE, Gabor KD, Stapczynski SJ, eds. Emergency Medicine: A Comprehensive Study Guide. 6^th ed. McGraw-Hill Co Inc; 2004:chap 257, p1583-1590.

Article Last Updated: Mar 6, 2008